Therapeutic Dyad Research Articles

From Dyad to Triad: On Psychodynamic Meanings of Psychiatric Treatment

The professions of psychiatry and psychotherapy are both complementary and competitive. This paper examines the dialectic tension between the two. It observes the complexity in having psychiatric evaluation and treatment in the context of ongoing psychotherapy. A referral to a psychiatrist is a meaningful, and a charged intrapsychic and interpsychic event for the patient as well as for the two therapists involved. The nature of the triangle is affected by the inner worlds of the three participants; therefore, the more awareness to the shared work, the better the communication between the three sides of this triangle. The referral to a psychiatrist by a psychotherapist is described as a specific type of an enactment in which the therapeutic dyad is becoming a tirade with all the implications attached. As opposed to the dichotomous perception of the psychiatric intervention as a temporary interruption and reduction of the therapy, this paper offers a model of cooperation between professions that will create a wider and deeper therapeutic space.

Client and therapist match on gender, age, and income: Does match within the therapeutic dyad predict early growth in the therapeutic alliance?

Because of the importance of the therapeutic alliance across psychotherapeutic treatments, it is important to study variables that predict the development of a positive therapeutic alliance. This study investigates if different levels of gender, age, and income match between therapists and clients predict early development of the therapeutic alliance. The sample consisted of 28 therapists and 547 adult clients receiving individual psychotherapy for depressive symptoms. There were no exclusion criteria and no control over treatment delivery. Session-to-session assessments of the therapeutic alliance were collected and a growth mixture modeling framework with a priori identified classes corresponding to different levels of therapist-client match was utilized to examine differential alliance growth trajectories. No differential effect of match on any level was found on initial ratings of the alliance. Across levels of attribute match, clients tend to rate the alliance positively. Regarding growth, a "youth effect" and an "affluence effect" was noted. Dyads where the therapist is younger than the client, and dyads where the therapist is from a higher income status than the client, show additional growth in the alliance beyond positive initial ratings. This is effect is not constant across sessions. Matching on gender, income, and age can be used for case assignment heuristic, in particular to produce additional growth in the alliance beyond initial positive ratings. Clinical and scientific consequences of the study are discussed.

Now Moments in Psychotherapy and Psychoanalysis and Baby Watching

ABSTRACTNow moments and moments of meeting are concepts derived from careful observation of mother-infant interaction using a theoretical frame that employs implicit knowing and nondeterminate sloppy processing. This dyadically derived construct has been transported and applied to the therapeutic dyad by Daniel Stern and his colleagues at the Boston Change Process Study Group (BCPSG) as a means to understand the something more that complements classically modeled psychoanalytic interpretation in promoting change. Tracking the origin, development and application of this idea opens the concept to scrutiny and will permit testing of its explanatory power, its flaws, and offer direction for future study.

When Time Stands Still: The Non-Interactive Interaction in the Psychoanalytic Encounter

This paper strives to shed light on the patient–therapist encounter at times and places where emotional life has stopped, both within the patient and in the therapeutic dyad. The term non-interactive interaction is coined to describe a manner of being together that does not possess the essential features of interaction: movement, encounter, and change. The paper explores the characteristics and effects of such dead areas in one’s soul and the various motivations for the therapist’s willingness to surrender himself to such areas, both those of his patient’s and of his own. Among these, the paper suggests, are the therapist’s love and dedication to his or her patients; his deep-rooted struggle to cope with and give life to some of his own deadened and traumatic self-states; and, perhaps most important, a mythical, hubris-like, valiant, and perennial urge to fight death. Two clinical examples are presented.

Reencounter With History and Memory Through a Therapeutic Process

In this co-authored paper, two clinical cases of extreme trauma from political persecution are presented, both of which were treated at ILAS, a center dedicated to treating survivors of such traumatization in Chile. In the first instance we refer to a woman who has been imprisoned and tortured in the first years of the dictatorship and who seeks psychotherapy 30 years after her experience. In the second case we refer to the daughter of whose parents were both detained and disappeared who seeks psychotherapy after she testifies in a film about the political repression in Chile. Both come to therapy many years after their original experience, triggered by testimony they gave for a documentary film about the Coup d’Etat in Chile. Using our understanding of intersubjective theory, most important the aspects of recognition and witnessing, we underscore the crucial role of the social context of the therapeutic dyad that allows the silence to lift. This gives way to the reparative function that words have when spoken to a live available person who represents society at large.

FROM PROXIMITY SEEKING TO RELATIONSHIP SEEKING: WORKING TOWARDS SEPARATION FROM THE “SCAREGIVERS”

Traditionally psychoanalysis showed interest in the child’s ambivalent relationship towards the object. Psychoanalysis also did not put great emphasis on the role of fear in a child’s life, in particular fear that has been inflicted by the caregivers (Slade, 2013). It was Mary Main who placed fear in the face of attachment needs and named it as disorganized attachment style. The research findings have given us a new lens into the way we see human behavior as displayed in many of our traumatized clients. The child’s need for both protection and autonomy are universal and has been at the heart of object relations and attachment theories. It is there where matters of core-relatedness and a developed sense of self are most involved. This paper discusses a client who suffered extensive sexual abuse. Her attachment to her mother, who I called her “scaregiver,” was preoccupied, enmeshed and coercive as well as being disorganized. The lack of boundaries and the controlling relationship the client had with her mother was re-enacted in the therapeutic dyad. This paper explores these dynamics and how attachment-based psychotherapy enabled a move towards safety for the client followed by better functioning, and more so enabled her to move towards intersubjectivity, a deeper understanding of her lack of boundaries, separateness and need for autonomy.

Women as counselling and psychotherapy clients: Researching the therapeutic relationship

The present study explores women clients’ experiences of the therapeutic relationship and their meaning making of the effective therapeutic dyad. The participants of the study were 27 female psychotherapy and counselling clients. Individual, semi-structured interviews were conducted and the data was analysed with the use of Interpretative Phenomenological Analysis. The findings indicated: (a) women clients’ attempt to define their relationship with their counsellor by comparing it to other interpersonal relationships, mostly to friendship or to family relationships; (b) their experience of the qualitative characteristics and the feelings associated with an effective therapeutic relationship; and (c) their experience of the counsellors’ role to the therapeutic outcome. The above results are fully discussed along with implications for practice.

Balancing clinical risk with countertransference management protects alliance

The working alliance has been recognized as a predictor of psychotherapy outcome across therapeutic orientations. Despite mixed findings regarding the effect of problem severity on the alliance formation, there is evidence suggesting that therapist factors may interfere in this association. This study examined how clients’ baseline clinical features affected the early alliance and the possible role of therapists’ countertransference management as a mediator. Thirteen therapeutic dyads were assessed at 2 different time points. Clients’ clinical dimensions were assessed prior to the 2nd session, and therapists’ countertransference management and clients’ ratings of the alliance were measured after the 2nd session. Positive associations were found between clients’ subjective wellbeing, social functioning, risk, and global psychological distress and countertransference management dimensions and total score. Empathy-based countertransference management suppressed the negative impact of clinical risk on alliance. Our findings suggest that clinical problems activate countertransference management, which in turn may buffer their negative effect on alliance.

Our Most Fundamental Task.

Our Most Fundamental Task.

“It was hard work every session”: Therapists’ view of successful psychoanalytic treatments

ABSTRACTObjective: To explore therapists’ experiences of the therapeutic process in successful cases of psychoanalytic psychotherapy. Method: A two-stage, mixed-method design was used. Sixteen successful cases were drawn from a sample of 92 young adults in psychoanalytic psychotherapy according to Jacobson’s criteria for reliable and clinically significant improvement. Therapist interviews at baseline and termination were analyzed applying Inductive Thematic Analysis. Results: Three core themes emerged: Being Particularly Motivated to be This Patient’s Therapist, Maintaining a Safe and Attentive Therapeutic Position, and Assiduous Work Every Session. The therapists experienced positive feelings towards the patient from the outset of treatment and described active, relational work that included paying attention to incongruities in the patient’s self-presentation and being mindful of patient’s avoidant behavior. The therapist’s motivation and attentive position made it possible to balance support and challenge in the therapeutic relationship. Conclusions: Successful therapeutic work presupposes positive expectations, an active therapeutic stance and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads.Clinical or methodological significance of this article: Our study indicates several factors that seem to characterize therapist expertise and can inform psychotherapy training. Successful therapeutic work presupposes positive expectations, an active therapeutic stance, courage to challenge the patient, and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads.

Mixed-Status Families and Immigration Interior Enforcement Policies: Effects on Clinical Practice and the Intraethnic Therapeutic Dyad

ABSTRACTThis article explores the sociopolitical and intersubjective enactments that unfolded when working with a mixed-status immigrant family facing parental deportation. Through the integration of a sociopolitical and intersubjective conceptualization, dynamics pertaining to inclusion, exclusion, domination, and subjugation are examined. The psychological exploration of the clinical treatment is guided by Altman’s (2010) three-person psychology and Stolorow’s (1991, 1993) theory of intersubjectivity. The analysis also incorporates dynamics pertaining to the ethnocultural transference and countertranference (Comas-Díaz & Jacobsen, 1991, 1995) and to associative identification processes (Shonfeld-Ringer, 2000). The case illustrates how dynamics of racialization, embedded within an increasingly White Nativist, ideological deportation immigration context, infiltrated the intraethnic, therapeutic relational encounter. The therapist took part in an intragroup, racialized reenactment that could have led to the therapist becoming part of the oppressive structure, but the therapist avoided doing so, explaining her internal process for rectifying the situation.

Fostering Reconnection and Resilience in Complexly Traumatized Youth: Integration of Play into Empirically Supported Treatment

Incorporating play therapy into empirically supported, trauma-informed treatments, such as trauma-focused cognitive behavioral therapy (TF-CBT), permits complexly traumatized youth to engage in therapeutic work within the context of play-based activities and provides a curative experience within the therapeutic dyad. Trauma-informed care with youth involves three tiers: safety and stabilization, trauma processing, and reconnection to family and community. This article focuses on the third and final phase of integrative treatment, which involves reconnecting traumatized children with aspects of themselves and others, working toward life goals, developing acceptance and forgiveness, and ending with therapeutic termination. This article presents therapists with interventions aimed at increasing self-regulation, creating a positive potential future, and reconnecting with self and others.

Three's a crowd: The impact of the organisation on the fee practices of volunteer therapists

AbstractAimsTo explore how therapists experience significant events surrounding the fee within a voluntary organisation setting when tasked with sustaining fee payments without financial gain to themselves.MethodA qualitative study involving semi‐structured interviews with twelve therapists of varying modalities, practising voluntarily within a counselling organisation. Participants shared a significant event surrounding the fee, their response, the sense they made of it and its lasting impact. Transcriptions were analysed using thematic analysis.ResultsFindings captured a rich set of experiences that roused powerful tensions involved in a therapeutic consideration of money, grouped into four main areas of impact: Impact from Within, Impact from Outside, Impact on Therapist and Legacy. Belief in its strengthening presence within the therapeutic dyad was in stark conflict with the threat it posed to rupture the relationship and revealed powerful dissonance, impacted further by the complex tripartite dynamic fostered by the organisation.ConclusionsMoney can be worked with creatively to facilitate movement within therapy. However, this is most often achieved only after therapist and client have tolerated considerable discomfort when money is concretely handled outside the therapeutic space. Less risk of rupture occurs when the fee is contained within the therapeutic relationship, and when responsibility is assumed by the therapist from the outset.

From Body Structure to Bodies in Resonance

This article takes the reader on a journey with two different parts. In the first one, contributions on the transference/countertransference theme provided by bioenergetic authors are presented giving an overview of the richness and creativity of each author. In the second part, a reflection about the impact of Attachment Theory, Relational Psychoanalysis and Neuroscience in the therapeutic relationship in Bioenergetic Analysis is provided. The impact of new concepts is exposed and the rethinking of old ones is revised. The result is a new, enriched view of the therapeutic relationship and its transferential/countertransferential processes where the therapeutic process becomes an interrelational somatosensory process within the therapeutic dyad. Some short clinical vignettes are provided.

Simulation modeling analysis of sequential relations among therapeutic alliance, symptoms, and adherence to child-centered play therapy between a child with autism spectrum disorder and two therapists.

This study examined the sequential relations among three pertinent variables in child psychotherapy: therapeutic alliance (TA) (including ruptures and repairs), autism symptoms, and adherence to child-centered play therapy (CCPT) process. A 2-year CCPT of a 6-year-old Caucasian boy diagnosed with autism spectrum disorder was conducted weekly with two doctoral-student therapists, working consecutively for 1 year each, in a university-based community mental-health clinic. Sessions were video-recorded and coded using the Child Psychotherapy Process Q-Set (CPQ), a measure of the TA, and an autism symptom measure. Sequential relations among these variables were examined using simulation modeling analysis (SMA). In Therapist 1's treatment, unexpectedly, autism symptoms decreased three sessions after a rupture occurred in the therapeutic dyad. In Therapist 2's treatment, adherence to CCPT process increased 2 weeks after a repair occurred in the therapeutic dyad. The TA decreased 1 week after autism symptoms increased. Finally, adherence to CCPT process decreased 1 week after autism symptoms increased. The authors concluded that (1) sequential relations differ by therapist even though the child remains constant, (2) therapeutic ruptures can have an unexpected effect on autism symptoms, and (3) changes in autism symptoms can precede as well as follow changes in process variables.

Joining revisited in family therapy: discourse analysis of cross‐cultural encounters between a therapist and an immigrant family

AbstractWith increasing diversity in therapeutic dyads, there has been renewed attention to the process of ‘joining’ in cross‐cultural encounters. Inspired by discourse analysis, we conducted a close reading of therapy transcripts between a Pakistani immigrant mother‐daughter dyad and a Canadian white female therapist in an outpatient clinic. Our findings illustrate detailed discursive interactions for joining techniques – selective joining, confirmation, and tracking – (1) where the therapist facilitates joining moments with the family and (2) where the same techniques are used to preclude further exploration of the family's cultural views. Consequently, the joining process is at times limited by the therapist's enactment of her own assumptions about the family's culture. Due to the doxic nature of cultural assumptions, a discursive analysis may help to prevent therapists from silencing their clients’ cultural voices and to be more reflexive of their assumptions, thus promoting joining.Practitioner points Joining in family therapy is a dynamic process The detailed analysis of joining moments can serve as an example for training therapists to examine their moment‐to‐moment responses to culturally diverse clients Therapeutic constructs/techniques (e.g. joining) cannot be decontextualized or conceptualized as apolitical and acultural Critical reflexivity may prevent therapists from unknowingly oppressing culturally diverse clients’ experiences and cultural identities

“Only Connect”: A Dictum for Psychoanalysis and Life

ABSTRACTClassical psychoanalytic tradition reinforced the idea that the patient use free association and the analyst was similarly limited to a rule of free-floating attention (listening) leading to interpretation of unconscious trends. The central aim of technique was to ensure that transference of the past onto the analyst would occur in a context that could permit interpretations of the transference. This article examines ways in which therapists use psychoanalytic theory to distance themselves from the relational aspect of the therapeutic dyad. The use of the therapists’ use of a professional self as a protective and distancing in the course of an analysis or therapy tends to derail the development of a successful therapeutic engagement.

Interrupted therapeutic process of a patient with borderline personality disorder / Proceso terapéutico interrumpido con un paciente con trastorno de personalidad borderline

Aim: to describe and understand an interrupted psychotherapy of a patient with Borderline Personality Disorder. Method: systematic, naturalistic and exploratory case study of the therapeutic dyad. The Therapeutic Cycles Model (TCM) and the Psychotherapy Process Q-Set (PQS) were the instruments used. Results: according to TCM, the case can be divided into two stages: one with cycles of change and one without cycles of change. According to the PQS, the themes addressed by the dyad were relevant to psychotherapy and related to patient diagnosis. However, the patient seemed to be uncommitted to the therapeutic process and did not rely on the therapist to solve her problems. The therapist’s attitudes were adequate but technical interventions were not prominent. The combination of patient and therapist data assisted in understanding why the psychotherapy was abandoned.

Therapist interventions and client ambivalence in two cases of narrative therapy for depression

Aim: We understand ambivalence as a cycle of opposing expressions by two internal voices. The emergence of a suppressed voice produces an innovative moment (IM), challenging the dominant voice, which represents the client’s problematic self-narrative. The emergence of the IM is opposed by the dominant voice, leading to a return to the problematic self-narrative. This study analyzed therapist and client responses to each other in episodes of ambivalence. Method: The therapeutic collaboration coding system (TCCS) assesses whether and how the therapeutic dyad is working within the therapeutic zone of proximal development (TZPD) by examining client responses to therapist interventions. We applied the TCCS to episodes in which a good- and a poor-outcome client in narrative therapy expressed ambivalence. Results: In both the good- and poor-outcome cases, the therapist responded to the emergence of ambivalence similarly, balancing challenging and supporting. The good-outcome case responded at the developmental level proposed by the therapist when challenged, while the poor-outcome case lagged behind the level proposed. Discussion: This supports the theoretical explanation that the therapist did not match client’s developmental level in the poor-outcome case, working beyond the client’s current TZPD and contributing to the maintenance of ambivalence.

Transference – Countertransference in (Evidence-Based) Sex Therapy

Sex therapists help patients resolve sexual difficulties and experience healthier, fully-expressed sexuality with themselves and with others. In order to be effective, sex therapy must be evidence-based, aiming to treat the symptoms presented by the client. However, as sexuality is expansive and complicated (both for the clients as well as the sex therapists), this (evidence-based) therapy cannot be done without taking into account the psychodynamic view in general, and the transferencecountertransference processes accompanying each therapeutic dyad (or sometimes, triad) in particular. After an introduction of sex therapy and of the PLISSIT model (Anon, 1976), I use a case study in order to demonstrate how awareness of transference-countertransference processes help overcome therapeutic bypasses in the therapy. I suggest an improved, integrative, PLISSIT conceptualization and possible implication of the use of dynamic understanding as part of evidence-based sex therapy.